70 year old female patient presented to casualty on 23/09/22 with
Chief complaints :
Fever since 4 days
Dry cough since 4 days
Pedal edema since 3 days
Chest pain since last night
Epigastric pain since last night
Shortness of Breath since morning
History of Present Illness :
Patient was apparently asymptomatic 7 years back, then she was diagnosed to have Hypertension f/b developed pedal edema which was insidious in onset, intermittent(on and off), pitting type and grade 2-3 since 7 years, increased on standing and working, relieved on taking rest. Patient had develoed fever since 4 days associated with chills and is of high grade. Cough since 4 days which is dry type of cough. Pedal edema since 3 days, chest pain and epigastric pain since last night, shortness of breath since morning which is of grade 4 type. H/o loose stools 2-3 episodes, watery in consistency, small quantity relieved with medications.
H/o burning micturition since 3 days
H/o Paroxysmal Nocturnal Dyspnea +
H/o anxiety and palpitations since 1 year (more in the morning)
Past History :
K/c/o Hypertension since 6-7 years and is on regular treatment (Amlodipine and Atenolol)
H/o surgery for swelling on the back 3 years back
Monoparesis of left upper limb 3 years back and got treated at outside hospital.
Personal History :
Appetite : Decreased
Diet : Mixed
Bowel and bladder movements : Regular
Sleep : Adequate
Addictions : None
Family History :
No significant family history
General Examination :
Patient is conscious, coherent and cooperative
Moderately built and moderately nourished
Pedal edema + since 3 days, pallor, icterus, cyanosis, clubbing, lymphadenopathy absent.
Vitals at the time of admission :
BP : 150/90 mm Hg
Temp. : 99.8 F
SpO2 : 78 on RA ; 98 on 5 lit of O2
PR : 90 bpm
RR : 24 cpm
Systemic examination :
CVS : S1, S2 heard
RS :
On auscultation : Crepitations heard bilaterally, BAE +
P/A :
On inspection :
Shape of abdomen - obese
No scars, dilated veins
On palpation : Tenderness in right and left hypochondrium
Auscultation : Bowel sounds are heard
CNS : NAD
Investigations :
1. Hemogram
23/09/22
24/09/22
25/09/22
28/09/22
2. CUE
23/09/22
26/09/22
27/09/22
3. ABG
23/09/22 - At the time of admission
24/09/22
25/09/22
26/09/22 (6:00 am)
26/09/22 (2:00 pm)
26/09/22 (9:05 pm)
27/09/22 (6:30 am)
27/09/22 (11:30 am)
27/09/22 (5:05 pm)
28/09/22 (6:20 am)
28/09/22 (5:10 pm) - pre-dialysis
28/09/22, 10:20 pm (Post-dialysis)
4. Random Blood sugar (23/08/22)
5. Fasting Blood Sugar (24-09-22)
27/09/22
6. Blood Urea :
23/09/22
24/09/22
25/09/22
26/09/22
27/09/22
28/09/22 - RFT
7. Serum Creatinine :
23/09/22
24/09/22
27/09/22
8. Serum electrolytes :
23/09/22
24/09/22
25/09/22
26/09/22
27/09/22
9. LFT :
23/09/22
27/09/22
28/09/22
10. Ultrasound(abdomen) report :
23/09/22
11. Urine electrolytes
23/09/22
12. ECG
23/08/22
13. Blood grouping and typing
14. Chest x ray
23-09-22
24/09/22
25/09/22
26-09-22
27/09/22
28/09/22
15. 2D Echo
24/09/22
25/09/22
27/09/22 - IVC - 1.7 (Non-collapsing)
28/09/22
16. LDH
25/09/22
17. Urine protein/creatinine ratio (25/09/22)
18. APTT (25/09/22)
28/09/22
19. Prothrombin Time (25/09/22)
27/09/22
28/09/22
20. Rapid Antigen Test - Negative (26/09/22)
21. RT-PCR
22. Anti HCV - Rapid and ELISA - Negative
23. HbsAg - Negative
24. HIV 1 & 2
25. Serum lactate(27/09/22) : 8.1
26. Serum Potassium (27/09/22) : 4.3
27. C/S
Blood c/s (27/09/22) :
Urine C/s (28/09/22)
ET aspirate (28/09/22)
Cross Consultation Notes :
26/09/22
27/09/22
Provisional Diagnosis :
PYREXIA 2° TO UROSEPSIS, AKI 2° TO AGN WITH HYPERTENSION WITH NON CARDIGENIC PULMONARY EDEMA
Treatment :
1. IVF - NS + U.O + 30 ML/HR/IV
2. INJ. NEOMOL 1 G IV IF TEMP. >101 °F
3. T. DOLO 650 MG PO/TID
4. NEBULIZATION WITH SALBUTAMOL 2ND HOURLY, BUDECORT 12TH HOURLY, DUOLIN 8TH HOURLY
5. INJ. PIPTAZ 2.25 MG IV TID
6. INJ. PANTOP 40 MG IV/BD
7. INJ. ZOFER 4 MG/IV/SOS
8. SYP. ASCORYL - D 15 ML/PO/TID
9. TAB. CARVEDILOL 3.125 MG/DL
SOAP Notes :
Day 3 (25/09/22)
S:
Patient is conscious, coherent and cooperative
Fever spikes + with chills, 4 episodes of loose stools since morning
O: Patient is on non Invasive ventilation
Vitals :
Bp: 140/60 mm Hg
PR: 92 bpm
RR: 20 cpm
Temp: 104 F @ 8 am
SpO2 : 94% on BI-LEVEL; 78% on RA
GRBS: 121 mg/dl @ 8 am
GCS - E4V5M6
Cvs: S1 S2 +
RS- Bilateral crepitations +
P/A- soft, non tender
A:
PYREXIA 2° TO UROSEPSIS, AKI 2° TO AGN WITH HYPERTENSION WITH NON CARDIGENIC PULMONARY EDEMA
P:
1. IVF - NS + U.O + 30 ML/HR/IV
2. INJ. NEOMOL 1 G IV IF TEMP. >101 °F
3. T. DOLO 650 MG PO/TID
4. NEBULIZATION WITH SALBUTAMOL 2ND HOURLY, BUDECORT 12TH HOURLY, DUOLIN 8TH HOURLY
5. INJ. PIPTAZ 2.25 MG IV TID
6. INJ. PANTOP 40 MG IV/BD
7. INJ. ZOFER 4 MG/IV/SOS
8. SYP. ASCORYL - D 15 ML/PO/TID
9. TAB. CARVEDILOL 3.125 MG/DL
Day 4 (26/09/22)
S:
Patient is conscious, coherent and cooperative
Fever spikes + with chills, 6 episodes of loose stools since last night
O: Patient is on non Invasive ventilation
Vitals :
Bp: 140/60 mm Hg
PR: 92 bpm
RR: 20 cpm
Temp: 104 F @ 8 am
SpO2 : 94 on BI-LEVEL; 78 on RA
GRBS: 121 mg/dl @ 8 am
GCS - E4V5M6
Cvs: S1 S2 +
RS- Bilateral crepitations +
P/A- soft, non tender
A:
PYREXIA 2° TO UROSEPSIS, AKI 2° TO AGN WITH HYPERTENSION WITH NON CARDIGENIC PULMONARY EDEMA
P:
1. IVF - NS + U.O + 30 ML/HR/IV
2. INJ. NEOMOL 1 G IV IF TEMP. >101 °F
3. T. DOLO 650 MG PO/TID
4. NEBULIZATION WITH SALBUTAMOL 2ND HOURLY, BUDECORT 12TH HOURLY, DUOLIN 8TH HOURLY
5. INJ. PIPTAZ 2.25 MG IV TID
6. INJ. PANTOP 40 MG IV/BD
7. INJ. ZOFER 4 MG/IV/SOS
8. SYP. ASCORYL - D 15 ML/PO/TID
9. TAB. CARVEDILOL 3.125 MG/DL
Day 6 (28/09/22)
ICU bed 3
70 yr old female, admitted on 23-09-22
Day 6
S:
Patient on mechanical ventilation.
One fever spike +
Ventilator settings :
SIMV - VC
RR - 20
FiO2 - 70
PEEP - 12
VT - 420
O:
Vitals
Bp: 130/80
PR: 88
RR: 33
Temp: 103.7
GRBS: 140 mg/dl
Cvs: S1 S2 +
RS- B/L diffuse crepitations present
P/A- soft, non tender
CNS- NAD
A:
Pyrexia 2° to Urosepsis with CAP, AKI 2° to AGN with non cardiogenic pulmonary edema with hypertension with severe ARDS
P:
Plan for dialysis i/v/o increased serum Creatinine and metabolic acidosis
1 session of dialysis done
Pre-dialysis :
Bp : 110/60
PR : 97 bpm
RR : 33 cpm
TEMP : 103.1 F
SpO2 : 91
GRBS : 143
Hb- 7.8
Pcv-24.8
Tlc-13000
RBC- 3.28
PLT- 2.95
FBS- 136
BLOOD UREA- 91
S.CR-1.9
S NA+ 133
S K + 4.5
S.CL+ 106
T.Bilirubin -0.52
D.bilirubin- 0.19
SGPT-22
SGOT- 39
ALK-261
T.protiens- 6
Albumin- 2.9
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